Treatment Outcomes in Psychotherapy and Psychiatric Interventions

Cost-effectiveness of treatment approaches is a preoccupation of clinical practice today. The skeptic would say that in practice this means a preoccupation with cost and a passing curtsey to effectiveness. Psychotherapy finds itself somewhat at risk in this environment because of the popular notion that most people who seek and receive psychotherapy are not that critically ill and probably get too much treatment even if they are. In response to these pressures there has been a major effort to document accountability through the use of formal measures of outcome. Paul Fink, in his foreword to this book, puts it this way: “Outcome studies are the most critical path to destigmatizing mental illness and bringing more individuals who require help into the care system.”

The most common way of describing the tension between effectiveness and cost is in terms of the dose-response curve that looks at outcome in relationship to the number of sessions. The researcher who has probably done most to popularize this measure is Ken Howard, one of the authors of this book.¹ Howard was one of the founders of the Society of Psychotherapy Research, now a thriving international organization. Somewhat paradoxically, the managed care industry is implementing programs today that are based on findings from the outcome literature that date back many years. It comes as a shock to many clinicians to learn that the current trend toward time-limited formats is actually in keeping with a well-documented understanding of the dose-response curve.²

The first section of the book provides a succinct survey of the paradigm shift that has occurred in regard to the interface between treatment decisions by the clinician and clinical outcome. This overview begins with an attempt to understand why formal research endeavors have failed to provide clinically useful answers. In short, this section addresses the difference between efficacy (as measured in formal controlled randomized studies) and effectiveness (as measured by studying results in a regular clinical setting).

The point is also effectively made that simple pre/post measures are inadequate for providing an informed opinion on the process of change. A strong case is made for sequential measures of clinical status that follow a predictable course.³ The authors suggest that a shift is required from generic treatment to prescriptive treatment. The latter requires that clinicians be able to draw on a spectrum of treatment models and choose or combine among them on the basis of a careful multidimensional assessment.

The second section addresses five specific aspects of a behavioral health service system that have strategic importance in service utilization and clinical outcome. The first focus is on outpatient psychotherapy. Examples are presented from instruments the authors have developed that provide a multidimensional measurement of change. Clinical examples are provided of patients who have better or worse outcomes and how tracking of sequential changes might be used to predict outcome. This notion of in-treatment feedback to the clinician is a fundamental and important aspect of the system. Expected change curves can be used to assess a given patient's response in comparison to a large sample with similar characteristics and problems. These change curves can also be used to compare treatment models, treatment sites, and individual clinicians.

Another chapter is devoted to the complex task of measuring change in an inpatient population. This is an important challenge given the high pressure to move patients quickly out of the hospital into less intensive care areas. Although somewhat technical, this chapter is important reading for any clinician operating within an inpatient facility environment. The authors critique some current measurement instruments and propose one of their own that is still under development.

A similar review is provided of the measurement challenges in substance abuse treatment programs. Once again the authors dissect the problems that have to be addressed and provide some thoughtful solutions, although these solutions are at an earlier stage of development. Substance abuse is another major contributor to the use of intensive clinical resources, and therefore there is a high payoff for maximizing cost-effectiveness of clinical services.

The final two chapters deal with advantages of combined treatment with psychotherapy and medications and with treatment within a primary care setting. The tone shifts in these chapters to deal more with “best practices” ideas with a view to selection of the most appropriate treatment model and the prevention of relapse. This material provides a useful perspective for both the clinician and the administrator and highlights the importance of how a service is organized in promoting consistent quality of care. The material is geared toward the role of mental health services within a medical setting. This is an important orientation because of the likelihood of behavioral health carve-out organizations being integrated into general medical service structures.

In addition, the book cites numerous examples of the use of group psychotherapy formats for the treatment of common disorders. This is likely to be an important area of change, with group becoming the default mode for many psychological treatments.⁴ The authors note both the effectiveness of groups and their acceptability if introduced properly.

The examples provided in the book are drawn from the COMPASS data system developed by the authors. Thus, other sources would be required for a more comprehensive guide to possible measurement tools.^{5, 6} It is also useful for the reader to bear in mind that the techniques being described are still in the early stages of development. For example, the exact shape of the dose-response curve is controversial, although there is general agreement that about 75% of patients entering the mental health service system are improved by the 6-month point.⁷ The hope of accurate prediction of what sort of patient will respond to what sort of treatment in what time frame remains to be confirmed. Nevertheless, the goal of achieving greater uniformity and accuracy through the use of outcome data remains worth pursuing.

Well written by experts and innovators in the field of measurement in health care settings, this book goes well beyond psychotherapy programs in its attention to broader service system design. The authors' expertise is evident in their ability to home in on core issues quickly. They have provided an informed overview of how clinical programs are being expected to merge outcome information with service system design. This should be mandatory reading for clinicians and administrators alike.